B Wolf and J
Brittenden
Vascular Surgery
Unit, Aberdeen Royal Infirmary, Aberdeen, UK
J.R.Coll.Surg.Edinb., 46, June
2001,154-158
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Keywords: Duplex scanning, post-operative complications, surgery, varicose veins
Varicose veins are present in 20-25% of adult females and 10-15% of men.(1)This common condition represents a considerable surgical workload, with an estimated 75,000 operations being performed each year in the United Kingdom (UK). (2) Up to 20% of varicose vein surgery is performed for recurrent veins, which have often arisen due to a technically inadequate first operation.(3) Although the pathophysiology is multifactorial, in primary varicose veins the main abnormality is valvular dysfunction. This may occur in the deep, perforating or superficial long and short saphenous veins.
CLINICAL FEATURES
Presenting complaints
The Edinburgh vein study has demonstrated that in the general population there is poor correlation between the presence of varicose veins detected on clinical examination and lower limb symptoms. The presence of reflux on duplex scanning, also has a weak association with symptoms. (2,4)
Varicose veins may be associated with a sensation of heaviness and itching and, in the presence of deep and superficial reflux, cramps and aching. However, all too often generalised aches and pains in the leg may be attributed to visible varicosed veins. Patients may present with complications such as bleeding, phlebitis and ulceration.
Indications for surgery
A large proportion of patients may wish surgery for cosmetic reasons or due to anxiety that their disease may progress to chronic venous insufficiency and ulceration. It should be emphasised that varicose vein surgery is not curative, and early surgery in uncomplicated veins will not prevent development of future varicosities. However, it has been shown, that quality of life is reduced in patients with varicose veins compared with the general population, and that this is improved by surgery. (5) Clear indications for surgery are signs of chronic venous insufficiency, superficial thrombophlebitis and bleeding.
Relative contra-indications
Before embarking on surgery it is important to elicit a history of previous deep venous thrombosis, major lower limb fracture, prolonged immobilisation or the so-called ‘white leg of pregnancy’. Clearly, surgery should not be performed on the superficial veins if they are acting as collaterals for occluded deep veins. These patients should, therefore, undergo further imaging to assess the patency of the deep veins. Arterial insufficiency is also a relative contraindication to varicose vein surgery and compression.
Clinical assessment
The general health of the patient should be assessed, to determine if they are suitable for surgery and whether this can be done on a day case basis. Appropriate pre-operative anaesthetic work-up should be performed as indicated by the age and co-morbidity of the patient. Clinical examination will allow assessment of the distribution of varicosities and indicate whether reflux is present in the long or short saphenous system or both. Tests such as the cough, tap and thrill tests have been shown to be inaccurate. (6) However, the combination of a hand-held doppler and tourniquet allows reliable identification of sapheno-femoral incompetence. (7) However, at the popliteal junction it is difficult to differentiate between short saphenous and popliteal reflux with the use of the hand held Doppler, and a duplex scan is justified.
It is important to look for signs of complicated varicose veins such as thrombophlebitis, lipodermatosclerosis, eczema and ulceration. The presence of extensive angiomatosis visible on the skin as a dark purple swelling in young adults should raise the possibility of the Klippel-Trenaunary syndrome. This is associated with absent or defective deep veins, the persistence of a lateral vein and increase in limb length. Treatment for this condition should, in most cases, be conservative. Clinical examination should allow detection of pathology in the arterial, neurological and musculoskeletal systems that may be a cause of symptoms.
The role of duplex scanning
Ideally, all patients with varicose veins would undergo duplex scanning, so that optimal surgery could be planned and performed. However, currently there is no clear evidence that such a policy reduces the rate of recurrence. In the presence of limited resources, duplex scanning is indicated in
(1) patients with suspected short saphenous incompetence, allowing confirmation of the diagnosis and identification of the junction,
(2) recurrent veins,
(3) complicated veins - such as lipodermatosclerosis and ulceration, and
(4) patients with a history suggestive of a previous deep venous thrombosis (Figure 1). Varicography and ascending phlebography are now infrequently performed.
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Informed consent should entail an explanation of the complications of varicose vein surgery. In the UK, varicose vein surgery is the most common source of medico-legal action directed against general and vascular surgeons. (8) Many cases arise as a result of poor communication between surgeon and patient. It is important to determine the patients expectations of surgery, to outline a realistic picture of outcome and to ensure that informed consent is obtained. Patients must be warned of possible complications. Common complications include minor haemorrhage, ‘track thrombophlebitis’, haematomas and wound problems (infection, lymph leak). Less commonly, damage may occur to the sural or saphenous nerves. Rare complications include direct injuries to underlying structures (deep veins, arteries and major nerves), permanent lymphoedema and thromboembolism.
Patient preparation
Preoperative marking should be performed with an indelible pen. This may be in the form of tramlines on either side of the vein. If the lines are placed directly on top of the varicosities, it is important to remove the ink before making avulsions otherwise tattooing may occur.
Routine antibiotic prophylaxis is not indicated in primary varicose vein surgery. It may have a role in patients undergoing redo-groin dissections or with overt ulcers at the time of surgery.
Heparin prophylaxis
A survey of the members of the vascular surgical society, showed marked variation in the use of heparin prophylaxis, with only 12% of members using it routinely and 71% on a selective basis. (9) In general, patients with complicated veins or other known risk factors such as obesity, increasing age and poor mobility should receive heparin prophylaxis.
Sapheno-femoral ligation
The patient is placed prone, with a degree of head down and the leg abducted. The incision should be made in the groin skin crease below and parallel to the inguinal ligament at the site of the sapheno-femoral junction (2 cm below and lateral to the pubic tubercle). The subcutaneous fat is spread out by the use of a self-retaining retractor. This usually allows identification of the long saphenous vein or one of its tributaries. The main tributaries are the superficial circumflex iliac, superficial inferior epigastric, superficial and deep external pudental veins. The superficial tributaries should be dissected, and followed were possible back to the secondary branch points and divided and ligated.(10) The long saphenous vein must not be divided until the sapheno-femoral junction has been clearly identified and dissected (Figure 2).
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Be aware of the superficial external pudendal artery that usually passes between the long saphenous and common femoral vein. It is important to ensure that the junction is well displayed (1 cm above and below the junction will usually suffice) and the small, usually medially located tributaries are divided. The long saphenous vein should be ligated flush to the junction. Most people either doubly ligate the long saphenous vein or transfix it. Before proceeding to stripping, the lower end of the wound should be retracted and the posterior-medial thigh vein identified and ligated.
Stripping of long saphenous vein
It has been clearly demonstrated that stripping reduces the rate of recurrence. (11) It is disappointing, therefore, that it is not universally performed. It is advisable to strip from above down as the reverse technique may result in the stripper being passed inadvertently into the deep venous system. The stripper can be passed either directly into the long saphenous vein by holding the end open with an arterial forceps or the end may be ligated and the stripper passed by a small side-hole. A ligature should be placed to prevent back bleeding. The leg is straightened and the stripper is gently manipulated down the vein. Stripping is usually performed to a hands-breath just below the knee; below this the saphenous nerve is more closely related to the vein resulting in an increased risk of injury. An incision is made in Langer’s lines over the distal end of the stripper that is then retrieved. Pressure should be applied over the stripper tract and any haematoma evacuated before wound closure. Inversion stripping has been shown to reduce the risk of haematoma as has multiple avulsions, although the latter may be less cosmetically appealing.
Multiple avulsions
Small 3-5 mm incisions may be made by an 11-scalpel, and the vein retrieved with the use of a phlebectomy hook and avulsed. Care should be taken to avoid nerve damage, in particular the common peroneal nerve at the neck of the fibula, the sural nerve in the midline of the calf posteriorly, and the long saphenous nerve in the lower medial calf. The avulsions may be closed with the use of steristrips.
Sapheno-popliteal ligation
It should be emphasised that the location of the saphenopopliteal junction is very variable and in 25% of cases the short saphenous vein will enter the deep veins at a higher level than the popliteal fossa. It is important, therefore, to mark the sapheno-popliteal vein pre-operatively with Doppler or more preferably by duplex scanning.
The patient is placed prone and a transverse incision is made over the previously marked site and the fascia divided. The short saphenous vein is identified and dissected carefully to the junction with the popliteal vein. There is usually an upward extension of the short saphenous vein known as the Giacomini vein which, if mistaken for the short saphenous, may make identification of the sapheno-popliteal junction difficult. In addition, gastrocnemius veins in the popliteal fossa may cause confusion. Care should be taken to avoid damage to the common peroneal nerve, and it should be noted that it is easy to tent up the popliteal vein. Once the T-junction is identified, the small tributaries should be ligated and divided and the short saphenous doubly ligated proximally. By flexing the knee it is usually possible to dissect 5-10 cm of short saphenous vein distally which may then be ligated and excised. It should be noted that stripping the short saphenous vein is associated with a high incidence of sural nerve injury.
Perforator ligation
The significance of perforating vein disease remains unclear even in patients with venous ulceration. Studies have shown that incompetence in perforating veins may be reversed following superficial saphenous vein surgery in the presence of a normal deep venous system. (12) In the past, surgery designed to divide the perforating veins, such as Cockett and Linton procedures, were associated with considerable morbidity. The recently developed technique of subfascial endoscopic perforator surgery (SEPS) has allowed perforating veins to be divided effectively with minimal morbidity through a small incision. SEPS is not indicated in primary uncomplicated veins but may have a role in addition to saphenous ligation in patients with venous ulcers and who have no evidence of previous deep vein thrombosis. (13)
Redo-groin surgery
A classification of recurrent varicose vein has been devised by Stonebridge et al (1995). (14) The majority of recurrences are due to inadequate groin surgery, i.e. failure to divide the saphenous vein flush with the common femoral vein, or to perform stripping.
The main principal with redo-groin surgery is that the sapheno-femoral junction (CSFJ) should not be approached directly through the previous scar tissue. This may lead to significant bleeding, which is difficult to control, inadvertent damage to the common femoral vein and an increased likelihood of inadequate surgery. The junction should be approached usually by a lateral approach. The artery is exposed and the dissection continued medially to the CSFJ that is ligated and divided, before more superficial dissection is commenced. It is important to strip the long saphenous vein if this has not been performed at the primary operation.
ADDITIONAL SURGICAL TECHNIQUES
Tourniquets
The use of tourniquets in varicose vein surgery has been shown to reduce blood loss, duration of surgery and subsequent haematoma formation in a randomised controlled trial. (15)
Formation of barrier at sapheno-femoral junction
Cribriform fascia, Gortex® or Mersilene mesh® have all been used at the junction in an attempt to reduce the rate of recurrence. (16,17)Results appear promising but to date there are no published randomised controlled trials of patching techniques in primary varicose veins. Disappointingly, a randomised-controlled trial involving patients with recurrent varicose veins has shown no reduction in recurrence following the use of a barrier.
Bandages
Bandages are applied at the end of the procedure in an attempt to curtail bruising. Patients are advised to wear compression stockings for a period of one week post-operatively. (18)
Local anaesthetic
The wounds should be infiltrated with local anaesthetic.
NEW DEVELOPMENTS
Currently, other promising techniques that may act as an alternative to surgical treatment are being evaluated. Closure of the long saphenous vein with endoluminal radio-frequency thermal heating of the vein wall in combination with phlebectomy, has been shown to be feasible, safe and effective at limited follow-up. (19) Phase III trials are currently evaluating a microfoam that is injected directly into the long saphenous vein under duplex surveillance, which results in occlusion of the vein.
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